Promise of Health Care Reform for Opioid Treatment Programs Dimmed by State Discrimination

Health care reform will bring increased access to opioid treatment programs (OTPs), but not as great an increase as the federal government keeps saying it will be. The impediment is the states—specifically, the anti-methadone states, which many are in one way or another. Either they won’t let Medicaid pay for methadone maintenance, or they won’t force private insurers to cover it, or both.

Medicaid expansion, a cornerstone of the Affordable Care Act (ACA), won’t mean anything if the state involved doesn’t allow Medicaid to pay for treatment in an OTP, Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD) told AT Forum. “For example, Georgia is a large state with many OTPs, but the state does not reimburse methadone treatment,” he said.

The other cornerstone of the ACA—exchanges, where individuals and small businesses can purchase affordable insurance—is also a state-by-state matter. California chose as its “benchmark” plan—the one that defines what benefits will be included in the exchange—a plan that doesn’t reimburse for methadone maintenance at all.

Of course, the federal Center for Medicare and Medicaid Services (CMS) has to approve the plans, for both Medicaid and exchanges. AATOD encourages CMS and the Substance Abuse and Mental Health Services Administration (SAMHSA) to include methadone, buprenorphine, and naltrexone for the treatment of opioid dependence as covered, Mr. Parrino said. “That is a critical issue of health care reform.” Since there are only three medications approved to treat opioid addiction, these medications should be part of the essential health benefits package, he said.

John O’Brien, the architect of the substance abuse treatment provisions of the ACA, is at the federal Department of Health and Human Services. He met with the AATOD board December 7, 2012. Mr. O’Brien also met with the AATOD board in Chicago in October 2010, and at that time recommended that states move to have Medicaid reimbursement for methadone maintenance, in order to be prepared for health care reform.

But in states that embrace methadone maintenance, and have a generous plan for Medicaid expansion and a generous benchmark package, there will be increases in patients—although not a “massive influx,” said Philip L. Herschman, PhD, chief clinical officer of CRC Health Group. He said that unlike residential programs, which have fixed numbers of beds, OTPs always have the capacity to expand. “It’s a matter of hiring the right number of counselors and nurses and other staff when you add patients,” Dr. Herschman told AT Forum. “You have to have enough capacity at the window to maintain decent wait times,” he said. “I don’t think there’s unlimited capacity, but there is some capacity in the system.”

But in some states, there are caps on the number of patients a clinic can have, regardless of the staffing, said Dr. Herschman, citing Washington State.

“There is no mandate for Medicaid to cover methadone maintenance,” agreed Dr. Herschman. “I don’t expect any immediate change in which states cover methadone maintenance. But in those states that already have methadone maintenance, we will see an increase in the number of patients.”

And it’s still not clear whether the exchanges, in which people will choose between different private insurance plans, will cover methadone maintenance. “That’s where the rubber meets the road,” said Dr. Herschman. “Methadone maintenance is not covered now in the vast majority of private plans. That leads one to believe that it won’t automatically be covered.”

The irony is that one year of treatment in an OTP with methadone is less expensive than one year of Vivitrol alone or one year of Suboxone film alone— and the treatment in the OTP includes a lot more than giving methadone. “OTPs provide a tremendous service,” said Dr. Herschman. Counseling, not just medication, is included, and treatment is comprehensive.

Another facet of the ACA—the health home, in which patients receive all medical care in one place—is something that a few OTPs are interested in—mainly ones that are affiliated with hospitals. But in general, it will be “very difficult for an OTP to be a health home,” said Dr. Herschman. Health homes will primarily be multi-specialty physician practices, and some will be mental health homes. “We’ve tried over the years to expand an OTP into a true outpatient substance abuse treatment program, offering all kinds of treatment, including drug-free,” said Dr. Herschman. “If you can expand, you have a chance of being that kind of mental health home,” he said, although CRC had only “limited success.” But making an OTP into a full medical home with primary care and other health services—that is not likely to happen except in rare cases, said Dr.Herschman.

HHS, CMS, and SAMHSA did not respond to repeated requests for interviews on the topic of health care reform and OTPs.